Eli's Rehab Report

Rehab provider finds cognitive impairment a pivotal risk factor.

A one-size-fits-all fall assessment form may cast too wide a net among your high-risk rehab patients. And that means staff can't focus their fall prevention efforts on those who need more special attention.

Case in point: Baltimore-based inpatient rehab facility at Kernan Hospital found that its standard fall risk assessment tool flagged 85 percent of its rehab patients at a high falls risk. The staff's goal, however, was to identify a much smaller scope -- those five to 10 patients on a unit to watch very closely and exercise more intensive falls prevention interventions with, says Phyllis O'Day, performance improvement coordinator for Kernan.

Looking for an alternative assessment tool, Kernan's fall team found literature describing a study that used FIM™ (once known as Functional Independence Measure) scores to identify patients at high risk for falling (Gilewski MJ et al. 2007 Nov-Dec;32(6):234-40). While many IRFs already use the FIM to assess their patients' rehabilitation potential and progress, SNFs and other inpatient rehab providers could benefit from this tool as well, when it comes to targeting falls risk at admission.

The Kernan team performed an internal statistical analysis of its patients' falls and found the highest rate of falls among those with cognitive deficits measured by the FIM.

Exception: The team found that if a patient can't get up independently, the person isn't at risk for falls whether she has cognitive deficits or not, O'Day clarifies. In response, the falls team selected three of the FIM categories that assess cognitive deficits (comprehension, memory and problem solving) to identify patients who are at high risk for falling -- at admission. The staff uses the FIM on all rehab patients, but not for three days or so after admission, O'Day reports. "But we couldn't wait that long to determine a patient's fall risk, which is usually the highest on the first day."

Heads up: Even though patients with cognitive deficits are likely to be at a higher falls risk, pay special attention to all patients when they return from therapy. Rehab therapist and consultant Kristen Mastrangelo finds that the majority of falls occur at this time. "They are tired and confident," she noted in a TCI-sponsored audioconference.

To reduce fall risk among patients flagged by the FIM, Kernan staff now reorients, reminds and redirects cognitively impaired residents about fall safety at each encounter. The facility also uses low beds and rubber mats on the floor by the bed to prevent injury from falls if they do occur in spite of staff's best efforts. In addition, the staff has implemented hourly rounding to preempt patients' needs before they try to get up, O'Day reports.

Good idea: Kernan is trialing a fall monitor triggered by a patient trying to get up without help. A pre-recorded message from a family member may say, for example, "Mom, don't get up without calling for help." But again, keep cognitive deficits in mind. "The alarms work for some patients and not for others, depending on the patient's cognitive problem," O'Day says.